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Out of Hours (OOH) Training for GP Specialty Registrars

Revised Position Paper 2010

COGPED OOH Position Paper Jan 2010

Out of Hours (OOH) Training for GP Specialty Registrars

POSITION PAPER [Revised January 2010]

Introduction

This revised document updates the position paper issued by COGPED in 2007 which provided guidance on the way in which General Practice Specialty Registrars (GP StRs) gain experience in out of hours (OOH) care. This update recognises the consolidation of the delivery of GP training, the greater awareness of the GP curriculum, and the increasing familiarity with the workplace based assessments, the role of Educational and Clinical Supervisors, and the development of the ePortfolio to record the learning experiences of GP trainees.. The delivery of OOH and unscheduled care continues to develop and change with a variety of models and processes offering patients a number of ways to access immediate medical care in the NHS. The RCGP has issued guidance that all GP trainees should have experience of 18 months in GP placements during their programme of GP training, and all Deaneries will be working to provide this, which has implications for the provision of OOH experience for GP trainees.

The Committee of General Practice Education Directors (COGPED) has consulted with the main stakeholders in this process, including the General Practitioners Committee (GPC), Royal College of General Practitioners (RCGP) and their Associates in Training Committee, and provider and commissioning organisations, to seek and incorporate their views throughout the development of this paper.

This update reflects the commitment by COGPED, expressed in the last version to continue to liaise with representatives from the GPC, the Registrar subcommittee of GPC, RCGP, providers of OOH services, NHS Employers, Primary Care Organisations (PCOs) and others to review and consider issues of importance in the future for OOH training of GP StRs in the light of experience and further development of the OOH services

Background

Since 31 December 2004 Primary Care Organisations have taken full responsibility for ensuring effective OOH provision, except in very exceptional circumstances. A substantial majority of general practitioners no longer undertake OOH work, though a number of GP Trainers and their colleagues from GP Training Practices continue to provide clinical supervision for GP Trainees undertaking out-of-hours sessions, and GP Deaneries normally provide training for these GPs working for OOH providers to undertake this Clinical Supervision role.

The strong view of all the organisations contributing to this document continues to be that the generalist role of the GP should be maintained and that newly accredited GPs will be expected to have demonstrated their ability to perform competently in OOH primary care.

It is the responsibility of the Postgraduate Deaneries to ensure that GP Speciality training provides the experience and assessment of generalist competencies, and for the Competent Authority to be satisfied that all generalist competencies have been successfully assessed in order for a Certificate of Completion of Training (CCT) to be issued.

COGPED OOH Position Paper Revision Draft of 66 Jan 2010

The way in which general medical services are delivered continues to evolve. The development of urgent care pathways and services for both out-of-hours and unscheduled care provides a variety of learning opportunities and environments for GP StRs to gain experience and competence in the care of acutely ill people.

The implementation of the Working Time Regulation (WTR) in 2009 requires all doctors (with certain approved exceptions) to work a maximum 48hours in any one week (which can be averaged over a longer time frame)..The working week for GP trainees in GP placements is defined as 10 sessions; a session being normally 4 hours, so there should not normally be a problem including the OOH sessions.

The ideas and competencies presented in this paper were initially espoused by McLean and Houghton and subsequently incorporated into the GP Curriculum. These are fully endorsed by COGPED. In order to develop the OOH training programme COGPED has facilitated the involvement and agreement of all the appropriate organisations and stakeholders in the provision of OOH primary care.

Definitions

Out of Hours service: General Practitioners working under either a GMS or PMS contract, will have a working day defined as 08.00 and 18.30 on all weekdays except public holidays. Thus, for those GPs providing GMS services, OOH is defined as that work undertaken between 18.30-08.00 and all day at weekends and on public holidays. Since the introduction of the last GMS contract in 2003, the Government undertook to increase the amount of time during the day that GPs were available to patients and balloted GPs in March 2008. As a result of this, GPs, through the GPC, agreed to provide ‘extended hours’ under a local enhanced service contract. This allowed GP Practices to provide NHS services in the early morning, in the evening and at weekends. However, in the majority of cases, this provided surgery services for non-urgent pre-booked patient contacts.Thus, OOH is continues to be taken to mean the type and style of working that takes place between the hours of 18.30-8.00 am for urgent and unscheduled patient contacts and does not include any experience gained in the GP Training Practice during extended hours.

In addition, the Department of Health and PCTs have responded to the recommendations of Lord Darzi (High quality care for all: NHS Next Stage Review final report June 2008) by stimulating a number of walk-in centres that are open for up to 15 hours a day, and for365 days a year. These can all provide opportunities for valuable experience in unscheduled care for GP trainees, though training placements in such organisations are rare.

This paper recognises that the processes for providing general practice and primary care, both during the normal working day and outside, are continuing to evolve and these processes provide different models of working, requiring different knowledge and competencies by GPs. The ability to undertake efficient yet safe telephone triage is one example.

It is important to make clear that these do not just refer to the management of emergencies, but also to the experience of dealing with patient contacts in a different quantity and context to the normal working day. In other words, emergency care is a feature of both in-hours and out-of-hours work but there are particular features of the out of hours period, such as isolation, the relative lack of supporting services and the need for proper self care, that require a specific educational focus.


Organisations in which GPStRs undertake OOH experience are part of the local education providers (along with Acute NHS Trusts, Psychiatric and Community Trusts, Hospices, and GP Training Practices and other locations) and such will need to provide an effective learning environment as well as appropriate supervision. PMETB and the Academy of Medical Royal Colleges has recently defined the roles and duties of supervisors (Workplace based Assessment – A guide for implementation).

Educational supervision of the GP StR: This is usually undertaken by the GP Trainer who undertakes overall supervision of the individual’s learning experiences, manages the process, commissions learning opportunities and is responsible for the delivery of formative assessment in the workplace and preparing the GP StR for the other elements of the MRCGP examination. Others may provide the educational supervisor with data to inform these processes.

Clinical supervision: may vary according to the learning situation. At its most basic, clinical supervision is a clinical governance issue ensuring the quality of care and patients’ safety. In this context it is taken to mean this, as well as the supervision of a GP StR’s learning and experience. In some areas the clinical supervisors is termed an associate or assistant trainer (and in secondary care, a consultant trainer).

It is desirable for the clinical supervisor to have additional skills to that of being a proficient professional and these will include the ability to teach, observe, assess and feedback to learners. The clinical supervisor could be a GP who is beginning the process of becoming a GP Trainer, or one who has recently retired, or a suitable GP who has had appropriate training or suitable GP who has had previous educational experience or who has received specific training as a supervisor. When it comes to the delivery of training in specific skills in particular, nominated clinical supervisors should be GPs, but clinical supervision can be carried out by other healthcare professionals as and when appropriate during an OOH shift.

Clinical Supervisors can be any suitably qualified health professional who has undertaken a Deanery approved Supervisors course and may include Deanery approved

Nurse Practitioners, Retained Doctor Educational Supervisors, Undergraduate Medical Student Teachers,

Currently approved GP Trainers will be able to work as Clinical Supervisors without needing to undertake the Deanery approved OOH Clinical Supervisor’s training course.

The GP Registrar will work under the supervision of a Deanery approved Clinical Supervisor, (CS), and only undertake tasks to a level no greater than that to which the CS is personally responsible.

If undertaking the roles and responsibilities of a doctor, the CS must be a qualified Medical Practitioner on the Medical Performers List

If undertaking the role and responsibilities of a Emergency Care Practitioner, the CS may be an appropriately qualified ECP, but any decision that would normally require referral or advice from a doctor must still be referred to the Lead Medical Supervisor and not be a decision made independently by the ST3


However, with the overall context of the GP StR’s training firmly in mind, Postgraduate Deaneries will want to ensure that experienced GPs continue to retain an appropriate and significant input into OOH training for GP StRs. Those doctors already approved as GP Trainers by their Postgraduate Deaneries will be automatically deemed qualified to supervise GP StRs.

Postgraduate Deaneries and some OOH providers have delivered educational packages or courses to enable GPs to develop the skills required for effective clinical supervision. There will be an ongoing need for such interventions to maintain the pool of clinical supervisors. Deaneries as well as clarifying the requirements of the job for the OOH provider organisation have a quality assurance function and should monitor the competencies of the clinical supervisors for this role,

Formal lines of communication between GP trainers, OOH clinical supervisors and others involved in clinical skills training are necessary to deliver continuity of information and feedback to ensure the validity of the trainer’s assessment of each GP StR.

Deaneries should ensure that Clinical Supervisors in OOH maintain and update their skills and are subject to a three yearly re-approval of their role, based on the feedback from GP Registrars.

The Assessment System: The formal assessment of the GP StR remains the responsibility of the Trainer, supported by evidence supplied by the GP StR, documented systematically in their ePortfolio as well as feedback from the clinical supervisor. Such evidence should include their own reflections on clinical encounters, professional conversations with their clinical supervisor or other naturally occurring evidence. GP StRs may choose to use an OOH encounter to submit for formal case-based discussion. It is essential that all records of OOH sessions and learning be recorded in the GP trainee’s ePortfolio and signed off by their Educational Supervisor.

The GPStR should use a record of experience and learning during their OOH sessions in their logbook/workbook, which should be signed by the OOH Clinical Supervisor at the end of each session, and which can be shared with their GP Trainer, both as a confirmation of the completed session and to support the reflective learning and continuation of the GPStR’s PDP. The Wales Deanery GP Registrar Out of Hours Training Workbook is a good model and is appended in Appendix 6.

To support the GP Trainer in making evaluations and facilitating learning outcomes for their GPStR in OOH competencies (particularly useful when the GP Trainer and Educational Supervisor may not observe their GPStR during any of their OOH placements), a self-evaluation and outcome linked learning workbook could be useful Such a model, as used in the KSS GP School, is attached at Appendix 3.

Royal College of General Practitioners View

The RCGP continues to hold the opinion that Certificates of Completion of GP Training license the holder to work in any capacity, unsupervised, in UK general practice and that GP training programmes should continue to be designed to equip GP Registrars to deal with all work that currently forms part of UK general practice. The opinion of the College is that GP StRs should continue to be trained in OOH work, as this remains a core part of the GP’s role.


The GP Trainer should evaluate the e-portfolio evidence and formative feedback from clinical supervisors in the OOH organisation, validating competencies when satisfied that these have been achieved, and confirming that the GP StR has undertaken the required level of exposure commensurate with the length of the GP component of their training programme.

In some instances the demonstration of some of the skills and competencies needed for OOH care, for example those exhibited in undertaking telephone triage, could also take place during the normal working day, and could be validated by the GP trainer from personal assessment.

Expectation of GP Postgraduate Deaneries

The aim of the training is to enable GP StRs to learn, develop, practice and maintain their competencies in OOH working

The Postgraduate Deaneries will expect all GP registrars to obtain the necessary OOH experience and training to achieve the competencies both as described in the GP curriculum and required for the MRCGP examination. In the rare situation where the Practice has not transferred responsibility for OOH services, responsibility for providing the experience and supervision of OOH training for the GP StR remains with that Practice. However, where GP Training Practices have no longer responsibility for OOH services, delegated arrangements for supervision should be made with the OOH service providers, with locally agreed criteria with the Directors of Postgraduate GP Education for training and the appointment of clinical supervisors. An approved GP Trainer providing services for an OOH provider could supervise his or her own and/or other GPStRs.

The evidence gathered by the GPStR in their e-portfolio and competencies achieved, should be formally reviewed by their Educational Supervisor on a six monthly basis, and form part of the Annual Review of Competence Progression process.

As an indicative benchmark of the time required to achieve, and maintain the competencies, it is likely that at least one session, at a suitable clinical intensity, per month, over the total period of training in a GP placement will be necessary in an appropriate and negotiated combination of learning environments. In some instances, the GP Trainer, in agreement with the GPStR, may indicate that additional time in this experience is required so that the competencies can be signed off. However, as training becomes increasingly focussed on the acquisition of competencies, arbitrary definitions of time as markers of completion of any part of training will become less reliable and relevant, although it is likely that a defined period of training in OOH will be retained for the foreseeable future, and Deaneries should ensure that they provide appropriate guidelines to the overall period of training in OOH that will be required by GP trainees.

GPStRs will be responsible for recording in their e-Portfolio the experience and reflection on all sessions that they attend as evidence of their competencies in OOH training.

The key out-of-hours competencies and their assessment

GPStRs should demonstrate competency in the provision of OOH care. The overall responsibility for assessment of competency is with the GP Trainer but GPStRs have a duty to keep the record of their experience, reflection and feedback in the competency domains.


The six generic competencies, embedded within the RCGP Curriculum Statement on ‘Care of acutely ill people’, are defined as the:

1. Ability to manage common medical, surgical and psychiatric emergencies in the out-of-hours setting.

2. Understanding of the organisational aspects of NHS out of hours care.

3. Ability to make appropriate referrals to hospitals and other professionals in the out-of-hours setting.

4. Demonstration of communication skills required for out-of-hours care.

5. Individual personal time and stress management.

6. Maintenance of personal security and awareness and management of the security risks to others


Provision of Out-of-Hours Services

There are a number of organisations involved in the delivery of OOH and unscheduled care services, including GP co-operatives, commercial services, NHS Direct, NHS 24, nurse triage, urgent care centres, and minor injury centres, primary care walk-in centres, GPs embedded within A&E departments and some remaining individual Practices and Practitioners who continue to provide cover for their Practice patients OOH. The model of service provided is of necessity varied; however there is a need for partnership and collaboration between all agencies at the local level. This will continue to be driven and shaped by national quality standards processes. It is expected that services will follow care pathways and patient journey/s, delivered in multi-professional settings, which will include GPs, nurses, paramedics, and A&E staff etc. and will continue to develop models of care that reduce the burden of unscheduled admissions to secondary care.

The various organisations provide a range of learning environments for GP StRs to gain experience and achieve competencies and should be expected and able to offer training for GP StRs.

The role of Primary Care Organisations

PCOs are mandated to secure OOH services, either by commissioning from appropriate organisations or consortia of organisations or, (though this is less frequent), by direct provision. The PCOs also have responsibility for the recruitment of competent GPs (as generalists who have adequate experience in the provision of OOH services) to serve in this area, though this responsibility is normally delegated to the OOH providers. Although the consensus opinion at present is that the element of the OOH service best provided by GPs is that derived form their training and experience as clinical generalists it is inevitable that future developments will occur and PCOs might consider the development of practitioners with special interests, including GPwSIs, in the area of OOH provision, not only to enhance the quality of the service and to provide leadership, but also as part of the overlying strategy for the retention of GPs.

PCTs will need to discuss with their local GP Postgraduate Deanery the increase in OOH opportunities that are needed for GP Registrars (GPRs) and take measures to ensure they can be delivered through arrangements currently in place to provide OOH services.’

The PCOs are encouraged to work closely with the Postgraduate Deaneries in establishing clinical and educational governance standards for training in OOH and assuring the quality of training in the OOH organisations.

The role of Postgraduate Deaneries

When commissioning services, PCOs must reassure themselves that the provider will not only deliver high quality OOH care, but also will have the capacity and capability to deliver the required training for GPStRs. They will also need to ensure that the provider complies with the quality assurance processes of the GP training programme delivered by each Deanery. Appendix 1 to this paper provides guidance on standards for clinical and educational governance for training in OOH.

The Deanery will need to work with PCOs and providers to develop mechanisms to ensure that suitable quality training is available and that incentives are in place to encourage and support the provider in delivering and monitoring the training.


The quality assurance of the GP training programme in OOH will include assessment of:

The induction processes for the initial exposure of GP StRs training in the OOH setting

The placement’s level of workload, educational facilities and the overall quality of the learning environment.

The clinical supervisor’s ability (which must include skills in observation and the ability to give feedback).

The capability and capacity of the OOH organisation in delivery of the clinical supervisory process.

It is mandatory that GP StRs maintain an e-portfolio of evidence of achieved competencies and experience which will include their own reflection on clinical encounters, professional conversations with and feedback from clinical supervisors and any formal or informal comments made by others appropriately involved in the process.

In order to support the skills of the OOH clinical supervisors Postgraduate Deaneries should provide programmes of training and skills development for them. The Postgraduate Deanery, in consultation with PCOs, may provide on going development programme as part of professional development of clinical supervisors.

Documenting OOH experience in the e-Portfolio

GPStR’s are asked to record each of their OOH sessions in the e-portfolio. The portfolio necessitates that each entry must be tagged before filing against, at least, one curriculum statement heading. Normally, in the case of an OOH session, this would be curriculum statement 7: Care of Acutely Ill People. The ‘OOH session’ learning log entry in the e-portfolio will prompt the GP StR with a number of set entry fields.

Clinical supervisors in OOH will complete a session feedback sheet (see Appendix 3) which the GPStR must share with the trainer/educational supervisor as evidence of attendance. This will allow the GP Trainer as a Educational Supervisor to validate the session. In cases where the Clinical Supervisor for the OOH session is the GPStR’s own GP Trainer and thus Educational Supervisor, it may not be necessary to complete this feedback sheet, and the Educational Supervisor may choose to comment within the shared entry, as below.

All OOH sessions entered into the e-portfolio must be shared and discussed with the Educational Supervisor. In particular circumstances, the Educational Supervisor may choose to ‘validate’ some of these as contributing to workplace-based assessment. In this case, the entry will also be tagged against one of the 12 professional competency areas.

At the end of the training programme (i.e. towards the end of the ST3 year), the Educational Supervisor will search for all OOH sessions in the ‘shared entries’ in the e-portfolio (there exists a filter facility for this) ensuring that the requisite number have been completed, or will be completed prior to the end of training. A declaration by the Educational Supervisor is then completed which will appear in the ‘progress to CCT’ section of the e-portfolio.

The Educational Supervisor should take into account any potential failure to complete the requisite number of sessions in the final assessment of the GPStR for their report, particularly


if there are concerns about the acquisitions of competencies. An unsatisfactory report may lead to the ARCP panel issuing an unsatisfactory outcome. .

The role of GP Trainers

GP Trainers should ensure that appropriate arrangements are in place, as part of their initial educational planning with the GPStR, for their sessions with the OOH service. The Trainer should ensure that the GP Registrar understands and is informed of the range of learning environments and opportunities locally that could deliver the required competencies. Examples might include:

Observation of NHS Direct Undertaking a course in telephone triage Updating CPR skills Participating in simulated emergency medical situation training Participating in a shift with a team of para-medics. Working with a GP in A&E Working in an OOH / Walk-in Centre Undertaking home visits for an OOH service

Sessions should take place at a time agreed by the trainer and GPStR, following a clear evaluation of the GPStR’s level of skill and competency and their learning needs. Normally this evaluation would take a month, during which time the GPStR will have been fully inducted into the GP Practice, and it may be advisable for GPStRs to not undertake any sessions with the OOH provider during this time.

GP Trainers should ensure that their GPStR undertakes an induction prior to starting. Most OOH providers now provide a formal induction to GP trainees to allow familiarisation with staff, processes and equipment. This is not only good Practice, but is now essential. In addition, the learning set in the local GP Training Programme (‘half-day release’) may also cover important local aspects, and Deanery may run courses for GP trainees, such as OOH communication skills and telephone triage.

GP Trainers should ensure that they debrief their GPR following their OOH session as soon as possible, and assess not only the learning made, and further areas for development, but also the quality of the experience of the OOH session provided to the GPR.

GP Trainers should regularly re-evaluate the level of supervision required by the GP StR and confirm this with the OOH provider. This will be dependent on the learning environment but the following structure is suggested:

Direct supervision the GP StR is supervised directly by the clinical supervisor [red] and takes no clinical responsibility.

Close supervision the GP StR consults independently but with the clinical [amber] supervisor close at hand e.g. in the same building.

Remote supervision the GP StR consults independently and remotely from the Clinical supervisor, who is available by telephone. An example of such a session would include a session ‘in the ‘car’ supervised by another GP ‘at base’. [green]

It is good practice, carried out by a number of OOH providers, to have a process of formal communication between the GP Trainer and the OOH provider organisation to facilitate the


move into amber or green shifts for the GP trainee. Trainers should, with the GPStR, review the portfolio on a regular basis and, taking into consideration other feedback from clinical supervisors, validate competencies that have been achieved. The example guidance as described above may be useful for this purpose.

The Responsibilities of GP Specialty Registrars

GPStRs are responsible for organising their sessions with OOH Providers and should ensure that the required number of hours are achieved commensurate with the duration of the GP component of their training programme. A number of OOH Providers operate an online shift booking system that GP trainees can have access to, normally following their induction and the issuing of a password. This will allow the GPStR to book directly. It is also good practice for Providers to have a nominated member of the administrative team to be the point of contact for GP trainees and to be able to deal with any queries related to shifts.

GPStRs should work in the OOH services, under supervision, in order to gain competence and confidence in the delivery of these services as a necessary part of becoming registered as GPs. The work of GP StRs in acquiring OOH competencies will be as part of their normal contract of employment.

It is part of any doctor’s professional responsibility to attend any commitment they have organised, and any non-attendance by GPStRs for booked OOH sessions, or premature finishing (unless for appropriate and compelling reasons, and agreed with the clinical supervisor and the OOH provider organisation) will be treated as a severe breach of professional behaviour.

GP StRs are responsible for maintaining an e-portfolio of evidence. For OOH such evidence should include their own reflections on clinical encounters, professional conversations with their clinical supervisor, relevant courses or reading and other naturally occurring evidence. GP StRs may choose to use an OOH encounter to submit for formal case-based discussion.

The Role of the OOH Service

OOH providers will continue to require service input from doctors trained in, and certified for general practice work. Each OOH provider is different and faces different challenges which impact on their ability to support and deliver OOH training. One example is the differences between urban and rural settings. It is essential that the Deaneries and PCOs work with the providers to understand the challenges which face them all. The OOH provider is in a good position to provide a range of training opportunities and the deaneries must work with them to develop this resource.

OOH providers should offer appropriate induction to the service including use of the computer system and any specific in-house protocols. Clinical supervisors should be trained and provide the appropriate level of supervision for the GP StRs level of experience, competence and confidence. OOH providers should also ensure that clinical supervisors have adequate time to debrief the GPStR and sign the GPStR’s record of each session. Appropriate documentary and oral feedback should be provided to both GPStR and GP Trainer. In order to support this, the OOH clinical supervisors will receive appropriate training commissioned or provided by the Postgraduate Deaneries.A number of OOH providers invite the GPStRs to give feedback on the quality of their induction and supervision, to allow further development of their service, and this can be recommended as a good model.


Whilst it is recognised that there are financial implications to OOH providers in delivering appropriate induction, training and clinical supervision, the more experienced GP StR can make a significant contribution to service at no cost to the provider The OOH provider in delivering a high quality learning experience has an opportunity of promoting participation in OOH work to the future workforce.

The role of the PCO

In commissioning and quality assuring OOH services the PCO needs to ensure that each OOH provider is able to provide the necessary training opportunities, has a sufficient number of trained clinical supervisors in their organisation and that these supervisors are appropriately trained and supported. These provisions should be reflected in the service level agreement with the provider. The PCOs are encouraged to consult with their GP Postgraduate Deaneries on standards for clinical and educational governance in OOH training.

Sessions in Out of Hours

The number of sessions worked by a GP StR to acquire the necessary competencies is likely to be directly related to the quantity of individual patient contacts, and thus the level of workload, provided by a routine OOH shift. in an urban setting, this is likely to require an indicative benchmark of a four to six hour session every four weeks adjusted in other settings on a pro rata basis. There are variations in the population numbers and patient demographics served by any one OOH organisation, therefore each GP Trainer and each Postgraduate Deanery should, focussing on the learning needs and acquisition of the required competencies, assess the provision of experience for each individual GP StR.

The educational value of experience gained in putting acquired competencies into practice is recognised and the purpose of having an indicative number of sessions worked by GP StRs, even if they can demonstrate the competencies, is that these sessions would increase the experience and exposure to different aspects of OOH work, particularly if they are undertaken in a variety of OOH settings. The negotiation of this is an issue for all involved organisations and GP Trainers. GP Trainees who are extending their planned period of GP training for remedial reasons should continue to undertake OOH sessions pro-rata, but in all cases Deaneries should seek to establish guidelines for the number of OOH sessions to be undertaken in order that specific learning objectives and competency achievement can be demonstrated, and to provide the evidence for successful sign-off at ARCP.

However, allowing for a necessary period of induction into general practice and primary care for GP StRs, the indicative benchmark of twelve sessions is likely to be necessary over a year of training in a GP placement, thus one session per month of training in the last year. GP StRs are now expected to undertake a minimum of 18 months in GP placements and GP Deaneries should ensure that appropriate additional sessions are undertaken pro-rata for placements in GP in the first and second years of training.

As per the guidance of the RCGP, ensuring that competencies that are achieved in the ST1 or ST2 years are maintained throughout training. It is expected that GP StRs in integrated training posts (ITPs) based in general practice should gain similar OOH experience to those colleagues undertaking traditional general practice placements. Those doctors who undertake training on a less than full-time basis should undertake the same number of sessions as their full-time colleagues but these would be attained over a longer timeframe.

The number of hours worked in any week should comply with the WTR. The Regulation states that the maximum length of work (currently 13 hours) and minimum rest periods (currently 11 hours).This is likely to be achievable in any GP placement. In order to experience


a broad range of clinical presentations it is desirable that GPStRs have experience of different models and shift times of the OOH service, and GP Trainers should be aware that a GPStR will need to be properly rested both before and after an overnight session.

Whilst it is preferable that OOH training should be distributed throughout the time as a GP StR in order that competencies acquired can be consistently demonstrated, local Deanery guidelines may provide for ‘block release’ options to deliver the required OOH experience However, there are serious potential disadvantages to this pattern which risks distorting the overall training experience and such an option should be regarded as the exception chosen for compelling reasons.

Exposure to a variety of community based emergency and OOH models, as described earlier, should be provided for GP StRs as part of their training programme. This should be acknowledged and negotiated with the GP Trainer, as part of the GP StR’s PDP. As GP training will now involve 18 months of GP placements, with the intention of this extending Deaneries may wish to ensure that OOH competencies appropriate to the learning stage of the GPStR (i.e. in their ST1 or ST2 year) may be better addressed at times within OOH contexts and learning environments other than the standard OOH provider session.

Induction to the OOH service delivered within GP trainee learning sets or done at the OOH centre by the provider may count as one of the inclusive sessions, provided this is a formal and structured induction session with learning objectives and outcomes that can be recorded on the Trainee’s ePortfolio.

Medico-Legal

The GP StRs will be subject to the normal processes of clinical governance, General Medical Council (GMC) regulations and civil law. Their contract of employment may remain with the GP Training Practice of their GP Trainer, or may be with another organisation such as a PCT. They may be supervised by their own GP Trainer who has approval and makes arrangements with the OOH Provider to work in this way, but more usually they will be supervised by a clinician who may not be known to them.

In the context of OOH training medical indemnity organisations have indicated that a GP StR’s standard membership will provide then with indemnity for the work they undertake as part of OOH training.

As the situation continues to evolve, particularly with regard to the employment of GPStRs, and as new models are developed there will be an ongoing need to keep the situation regarding medical indemnity under review and OOH providers will need to ensure that their insurance is adequate to cover their own liabilities in connection with the work done for them by GP StRs.

Review

COGPED recognise that the process and structures for delivering OOH care will continue to evolve, thus the processes for delivering training for OOH care for GP StRs will require regular formal review and further consultation. To this end, the steering group of appropriate stakeholders should continue to exist and meet regularly.


References

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17. Workplace Based Assessment. A guide to implementation. PMETB 2009 http://www.pmetb.org.uk/fileadmin/user/QA/Assessment/PMETB_WPBA_Guide_20090501.pdf


http://www.rcgp-

http://www.mmc.nhs.uk/pdf/Gold%20Guide%202009%20-%20Third%20edition%20v1.pdf

http://www.gpkss.ac.uk/who/deanery/pdfs/DOHguide.pdf

http://www.gmc-uk.org/guidance/good_medical_practice/index.asp

http://www.bma.org.uk/ap.nsf/Content/worktimeregs?OpenDocument

http://www.rcgp.org.uk/nmrcgp_/nmrcgp/wpba_and_e-portfolio/competency

http://www.rcgp-curriculum.org.uk/rcgp_-%20_gp_curriculum_documents/gp%20_curriculum_statements.aspx

Appendices

Appendix 1 DH letter

Appendix 2 Guide to experiential and learning progression of GP trainees in OOH sessions

Appendix 3 Guide to the assessment of OOH competencies

Appendix 4 Template for Quality Management

Appendix 5 Model Honorary Contract.

The following individuals and organisations have contributed to writing the original version of this position paper;

Mr M Beattie, NHS EmployersDr A. Benjamin NHS Alliance Urgent care Providers Representative, and Walsall Out-of-Hours Community Benefits Society (or CBS for short).Dr Jill Edwards, Royal College of General PractitionersDr K Hill, Deputy GP Director, East Midlands Healthcare Workforce Deanery Dr I McLean, Deputy GP Dean KSS, GP, representing UKCEA Dr Jane Mamelock - North West Deanery Dr T Swanwick, GP Director, London Deanery Dr A Thompson, GP Registrar Sub-Committee, BMA Professor A Tavabie - KSS GP Dean & Deputy Dean Director (Chairman)

And for this 2009 reviewProfessor A. TavabieDr. I. McLeanDr. W. IrishDr. R. Weaver


Appendix 1


Appendix 2Guidance to progression of sessions for trainees

Suggested structure to ST3 training

As a guide, the 12 month year can be broken into ”three stages”: If placements in general practice are contiguous, these stages will occur over that greater period of time. GPStRs who undertake a GP placement in their ST1 and ST2 years would not normally be expected to move beyond the Red or Amber sessions in that time.

RED Session (Direct Supervision) First stage (months 1-2)

GP Trainer (GPT) or Clinical Supervisor works an OOH session with the ST3 but the GPT/CS sees patients and ST3 remains supernumerary.

The ST3 should progressively take personal clinical responsibility for a caseload, initially under direct supervision of the GPT/CS, (as in a Joint Surgery format).

The ST3 may then, with agreement of their GPT/CS, independently see and report back after each consultation to agree a management plan

AMBER session (Close Supervision) Second stage (months 3-5) GP Trainer or Clinical Supervisor and ST3 both attend Coho sessions and both see patients. The ST3 should be able to manage most cases without direct reporting to their supervisor.

GREEN sessions (Remote Supervision) Third stage (months 6-18) Please note all OOH must be completed by the final ARCP.

The ST3 trainee works the OoH session with the GPT/CS being directly contactable, elsewhere on-site, at home or in a `roving’ car.

The GPT/CS must be able to give advice on request, assess the situation and in very rare circumstances be available for joint consultation. More usually advice on process, necessity for admission or availability of other agencies can be given over the phone.


Appendix 3KSS Guide for GP Trainers to assess OOH competencies

KSS GPKSS GP SchoolSchool

Guide to AssessingGuide to AssessingOOH CompetenceOOH Competence

Of GPStRs in GP trainingOf GPStRs in GP training


Index

Page

INTRODUCTION 3

Background 3

Rationale 3

The Key Out of Hours Competencies

ASSESSMENT OF OOH COMPETENCE

3

4

1. Trainee self-assessment 4

2. Assessment of knowledge of common OOH and important emergency scenarios

4

3. Declaration by OOH Supervisor 4

4. Audio-COT assessment

5. OOH CbD assessment

CLINICAL SETTINGS

PALLIATIVE CARE

4

4

5

5

GLOSSARY

APPENDICES

5

Appendix A – GPStR OOH Self-Assessment Tool

Appendix B – OOH Care Short Answer Questionnaire

Appendix C – Declaration by OOH Supervisor

HYPERLINKS (press Ctrl + click to follow link)

RCGP Curriculum Section 7: Care of Acutely Ill People RCGP Curriculum Map: 07 Care of Acutely Ill People COGPED Out of Hours Position Paper


http://www.cogped.org.uk/document_store/1186480594_1_jxpuCmxd.doc

http://www.rcgp-curriculum.org.uk/extras/curriculum/statementDetails.aspx?id=14

http://www.rcgp-curriculum.org.uk/pdf/curr_7_Acutely_ill_people.pdf

http://www.kssdeanery.org/siteuploads/Appendix%20C%20Declaration%20by%20OOH%20Supervisor.doc

http://www.kssdeanery.org/siteuploads/Appendix%20B%20GPSTP%20OOH%20Care%20SAQ.doc

http://www.kssdeanery.org/siteuploads/Appendix%20A%20GPStR%20Self-Assessment%20OOH.doc

INTRODUCTION

The purpose of this document is to provide guidance on how to assess competence in out of hoursclinical practice (OOH Competence) of GP Specialty training Registrars (GPStRs).

This document should be read in conjunction with:

RCGP Curriculum Section 7: Care of Acutely Ill People;

COGPED Out of Hours Position Paper.

Background

The assessment of OOH Competence is an essential element of the workplace based assessment component of the nMRCGP examination. Educational Supervisors are therefore required to sign off their GPStR as being competent in OOH as part of the final review. A GPStR cannot therefore apply for their Certificate of Completion of Training (CCT) without this OOH Competence box being ticked.

Rationale

This guide is intended to help with two potential problems:

1. Many Educational Supervisors do not directly supervise their GPStRs in OOH practice.

Therefore it can be difficult to know what evidence can be used to assess the OOH Competence of their GPStR.

2. To ensure good clinical governance OOH providers need some kind of assessment to

know when a GPStR is ready to move from closely supervised (Amber) shifts to remotely supervised (Green) shifts.

The Key Out of Hours Competencies

The six generic competencies, embedded within the RCGP Curriculum Statement on ‘Care of acutely ill people’, are defined as the:

1. Ability to manage common medical, surgical and psychiatric emergencies in the out-of-hours setting.

2. Understanding of the organisational aspects of NHS out of hours care.

3. Ability to make appropriate referrals to hospitals and other professionals in the out-of-hours setting.

4. Demonstration of communication skills required for out-of-hours care.


http://www.cogped.org.uk/document_store/1186480594_1_jxpuCmxd.doc

http://www.rcgp-curriculum.org.uk/pdf/curr_7_Acutely_ill_people.pdf

5. Individual personal time and stress management.

6. Maintenance of personal security and awareness and management of the security risks to others.

Assessment of OOH Competence

GPStRs need to demonstrate competency in the provision of OOH care. The overall responsibility for assessment of competency is with the Educational Supervisor but GPStRs have a duty to keep the record of their experience, reflection and feedback in the competency domains. This record should be kept within the e-Portfolio.

The assessment of OOH Competence should be triangulated from several sources of evidence. This may include:

1. An initial trainee self-assessment against GP Curriculum learning outcomes

2. An assessment of knowledge of common OOH and important emergencyscenarios

3. A declaration by the OOH supervisor

4. An audio-COT assessment

5. An OOH CbD assessment

An Educational Supervisor may also use additional evidence from in-hours practice that may demonstrate competence of learning outcomes from the RCGP Curriculum Statement on ‘Care of acutely ill people’.

1. Trainee self-assessmentGPStRs should be encouraged to complete the OOH Self-Assessment Tool (Appendix A) prior to starting their OOH sessions. This will not only familiarise them with the learning outcomes from the GP Curriculum, but also allow them to set specific learning objectives which they may wish to record on their PDP.

The Self-Assessment Tool may be re-visited at intervals throughout the training programme and prior to the final review to assess progress.

2. Assessment of knowledge of common OOH and important emergency scenarios

GPStRs need to be able to manage both common conditions and recognise important medical emergencies with which they may be faced whilst doing OOH clinical practice. This can be assessed using the OOH Care Short Answer Questionnaire (Appendix B).

3. Declaration by OOH SupervisorBefore the GPStR can progress from doing closely supervised (Amber) shifts to remotely supervised (Green) within the OOH organisation it is good practice for the OOH Supervisor who has been supervising the GPStR to sign a declaration that they have no concerns with the


GPStR’s performance. This should then be shared with both the OOH organisation and the GPStR’s Educational Supervisor. Such a declaration will be based on observed practice whilst under close supervision (Appendix C).

4. 4. Audio-COT AssessmentAn assessment of the GPStR’s performance can be made using an audio recording of a telephone consultation that the GPStR has performed whilst doing an OOH shift. This should be recorded in the GPStR’s e-Portfolio in the same way as one would record a video-COT, using the same assessment framework.

The OOH provider would need to provide the audio recording for the purpose of this assessment. Alternatively the assessment could be done “live” using a training headset or in a observed OOH surgery if the opportunity arises.

5. 5. OOH CbD AssessmentA CbD assessment can be done using cases from the GPStR’s OOH practice. The OOH provider would need to provide a print out of the OOH clinical records for the purpose of this assessment. The Educational Supervisor may wish to focus the discussion around relevant learning outcomes from the RCGP Curriculum Statement on ‘Care of acutely ill people’. The assessment would be recorded in the GPStR’s e-Portfolio.


CLINICAL SETTINGS - that can provide evidence to support assessment of OOH Competence

OOH Provider

- OOH Base Surgery

- OOH Telephone Triage

- OOH Home Visit Car

Primary Care Walk in Centre

Primary Care Centre in A&E department

N.B. In-hours on-call duties can provide some supporting evidence. However, in-hours work does not provide the opportunity to demonstrate the six key OOH competencies (p.3). It is therefore essential that GPStRs work in settings that provide this opportunity as outlined in the COGPED Out of Hours Position Paper.

PALLIATIVE CAREPalliative care can form a significant part of OOH work. GPStRs should be familiar with the learning outcomes of section 12 of the GP Curriculum:RCGP Curriculum Section 12: Care of People with Cancer and Palliative CareThey may wish to use the self assessment tool for Palliative Care:GPStR Self Assessment Tool for Oncology & Palliative Care

GLOSSARY OF ABREVIATIONS

GPStR GP Specialist training Registrar

OOH Out of Hours

CCT Certificate of Completion of Training

RCGP Royal College of General Practitioners

COGPED Committee of General Practice Education Directors

COT Consultation Observation Tool

CbD Case-based Discussion


http://admin.kssdeanery.org/files/gp.kssdeanery.org/gpstrself-assessmentoncologypalliativecare.doc

http://www.rcgp-curriculum.org.uk/PDF/curr_12_Cancer_&_Palliative_Care_v1_1_feb09.pdf

PDP Personal Development Plan


Appendix 3a

GP Specialty Training Programme GP Specialty Training Programme OOHOOH

GPStR Self-Assessment ToolGPStR Self-Assessment ToolHow to use this toolTo help you identify your learning needs in relation to the GP Curriculum we have attached a list of learning outcomes and the knowledge base taken from section 7 in the form of a confidence rating scale. You will then be able to use it to help you identify areas that require development.

WHAT learning needs identified? ( where rated as less confident)

HOW may this be addressed?Learning objective

How will you ASSESS your learning?e.g. CbD / COT / DOP


WHAT learning needs identified? ( where rated as less confident)

HOW may this be addressed?Learning objective

How will you ASSESS your learning?e.g. CbD / COT / DOP


7 CARE OF THE ACUTELY ILL PATIENT – KNOWLEDGE BASE OOHOOH

Please rate your confidence in your knowledge of the following areas

Not Confident Slightly Confident Confident Very Confident

Symptoms

Cardiovascular – chest pain, haemorrhage, shock.

Respiratory – wheeze, breathlessness, stridor, choking.

Central nervous system – convulsions, reduced conscious level, confusion.

Mental health – threatened self-harm, delusional states, violent patients.

Severe pain.

Common and/or Important conditions Shock (including no cardiac output), acute coronary syndromes,

haemorrhage (revealed or concealed), ischaemia, pulmonary embolus, asthma.

Dangerous diagnoses: e.g. MI, PE, SAH, appendicitis, limb ischaemia, intestinal obstruction, meningitis, AAA, ectopic pregnancy, acute psychosis, visual problems that can lead to blindness.

Common problems that may be expected with certain practice activities: anaphylaxis after immunisation, local anaesthetic toxicity and vaso-vagal attacks with, for example, minor surgery or intra-uterine contraceptive device


insertion.



Parasuicide and suicide attempts.

Treatment

Pre-hospital management of convulsions and acute dyspnoea.

Investigation

Blood glucose.

Other investigations are rare in primary care because acutely ill patients needing investigation are usually referred to secondary care.

Emergency Care

The ‘ABC’ principles in initial management.

Appreciate the response time required in order to optimise the outcome.

Understand the organisational aspects of NHS out-of-hours care.


Understand the importance of maintaining personal security and awareness and management of the security risks to others.



Resources

Appropriate use of emergency services, including logistics of how to obtain an ambulance/paramedic crew.

Familiarity with available equipment in own car/bag and that carried by emergency services.

Selection and maintenance of appropriate equipment and un-expired drugs that should be carried by GPs.

Being able to organise and lead a response when required, which may include participation by staff, members of the public or qualified responders.

Knowledge of training required for practice staff and others as a team in the appropriate responses to an acutely ill person.

Prevention

Advice to patients on prevention, e.g. with a patient with known heart disease, advice on how to manage ischaemic pain including use of glyceryl trinitrate (GTN), aspirin and appropriate first-line use of paramedic ambulance.


7 CARE OF THE ACUTELY ILL PATIENT –LEARNING OUTCOMES OOHOOH

Please rate your confidence against the following statements taken from learning outcomes of the GP Curriculum

Strongly disagree Disagree Agree Strongly Agree

Primary Care management

I can recognise and evaluate acutely ill patients

I can describe how the presentation may be changed by age and other factors such as gender, ethnicity, pregnancy and previous health

I can recognise death

I can demonstrate an ability to make complex ethical decisions demonstrating sensitivity to a patient’s wishes in the planning of care

I can provide clear leadership, demonstrating an understanding of the team approach to care of the acutely ill and the roles of the practice staff in managing patients and relatives

I can take responsibility for a decision to admit an acutely ill person and not be unduly influenced by others, such as secondary care doctors who have not assessed the patient

I can coordinate care with other professionals in primary care and with other specialists.

Person-centred care

I can describe ways in which the acute illness itself and the anxiety caused by it can impair communication between doctor and patient, and make the patient’s safety a


priority.



I can demonstrate a person-centred approach, respecting patients’ autonomy whilst recognising that acutely ill patients often have a diminished capacity for autonomy.

I can describe the challenges of maintaining continuity of care in acute illness and taking steps to minimise this by making suitable handover and follow-up arrangements.

I can describe the needs of carers involved at the time of the acutely ill person’s presentation.

I can demonstrate an awareness of any conflict regarding management that may exist between patients and their relatives, and act in the best interests of the patient.

Specific problem-solving skills

I can describe differential diagnoses for each presenting symptom.

I can decide whether urgent action is necessary, thus protecting patients with non-urgent and self-limiting problems from the potentially detrimental consequences of being over-investigated, over-treated or deprived of their liberty.

I can demonstrate an ability to deal sensitively and in line with professional codes of practice with people who may have a serious diagnosis and refuse admission

I can demonstrate an ability to use telephone triage


I can demonstrate the use of time as a tool and to use iterative review and safety-netting as appropriate




A comprehensive approach

I can recognise that an acute illness may be an acute exacerbation of a chronic disease.

I can describe the increased risk of acute events in patients with chronic and co-morbid disease.

I can identify co-morbid diseases.

I can describe the modifying effect of chronic or co-morbid disease and its treatment on the presentation of acute illness

I can recognise patients who are likely to need acute care and offer them advice on prevention, effective self-management and when and who to call for help

Community orientationI can demonstrate an ability to use knowledge of patient and family, and the availability of specialist community resources, to decide whether a patient should be referred for acute care or less acute assessment or rehabilitation. Thus using resources appropriately.

I can deal with situational crises and manipulative patients, avoiding the inappropriate use of healthcare resources.

A holistic approach


I can demonstrate an awareness of the important technical and pastoral support that a GP needs to provide to patients and carers at times of crisis or bereavement including certification of illness or death.



I can demonstrate an awareness of cultural and other factors that might affect management of an acutely ill patient.

Contextual aspects

I can demonstrate an awareness of legal frameworks affecting acute healthcare provision especially regarding compulsory admission and treatment.

I can demonstrate an awareness of the tensions between acute and routine care and impact of workload on the care given to the individual patients.

I can demonstrate an understanding of the local arrangements for the provision of out-of-hours care.

Attitudinal aspectsI can demonstrate an awareness of my personal values and attitudes to ensure that they do not influence my professional decisions or the equality of patients’ access to acute care.

I can identify patients for whom resuscitation or intensive care might be inappropriate and take advice from carers and colleagues.

I can demonstrate a balanced view of benefits and harms of medical treatment.


I can demonstrate an awareness of the emotional and stressful aspects of providing acute care and an awareness that I need to have strategies for dealing with personal stress to ensure that it does not impair the provision of care to patients.




Scientific aspects

I can describe how to use decision support to make their emergency interventions evidence-based, e.g. Cochrane, Clinical Knowledge Summaries (PRODIGY), etc..

I can demonstrate an understanding of written protocols that are available from national bodies and how these may be adapted to unusual circumstances.

I can evaluate my performance in regard to the care of the acutely ill person; including an ability to conduct significant event analyses and take appropriate action.

Psychomotor skills

I can perform and interpret an electrocardiogram.

I can perform cardiopulmonary resuscitation of children and adults including use of a defibrillator.

I can control a haemorrhage and suture a wound.

I can pass a urinary catheter.

I can use a nebuliser


Appendix 3b

GP Specialty Training Programme GP Specialty Training Programme OOH CARE SHORT ANSWER QUESTIONNAIREOOH CARE SHORT ANSWER QUESTIONNAIREThis short answer questionnaire has been adapted from the Canbury Emergencies in General Practice Questionnaire. It can be used to assess knowledge of both common conditions and medical emergencies that may present in OOH clinical practice.The questionnaire can be conducted either as an oral or written assessment.

For each scenario the following questions should be asked:

1. What is your diagnosis

2. What is your differential diagnosis

3. How would you manage this scenario in an OOH situation

Cardiovascular system

78yr man SOB at night in winter

Middle-aged man, central chest pain and refers to left arm

27yr woman with sudden onset of pleuritic pain and haemoptysis

58yr sudden onset painful, cold pale leg

Faintness, abdominal and back pain in 81yr man

41 yr woman with sudden onset of occipital headache

21 yr woman unilaterally painful swollen lower leg

33yr man sudden onset unilateral headache


61yr female increasingly severe chest pain and shortness of breath over a few days

66yr female palpitations and breathless

Gastrointestinal

28 yr old man with haematemesis after stag night

Worsening abdominal pain in a 46yr old man with history of dyspepsia

Vomiting in a 6 week baby boy

Blood stained diarrhoea in 70 year old

Severe bleeding PR in 51yr old woman

Abdominal pain after minor RTA in 33yr old

44 year old woman with right upper quadrant abdominal pain and fever

14 yr old boy with severe abdominal pain and vomiting

Diarrhoea and vomiting 26yr old woman for 48hrs

Diarrhoea and vomiting 6yr old boy with fever

Orthopaedics

18 month old refusing to walk

14 year old with painful hip


75 year old lady unable to move one leg

49 yr man with back pain and unable to pass urine

3yr old girl with painful arm and not moving her elbow

22yr old footballer with tender swollen ankle

Ophthalmology

30 yr old man with sore eye after changing car exhaust

Severe painful eye with vomiting in 50yr old woman

Respiratory

3yr old feels hot, looks ill, breathing sounds chesty, quiet

Chest pain in 33yr man, sudden onset of breathlessness

Hot, sweaty child, sore throat and dribbling, unable to swallow

5yr old boy with fever and earache

Acute shortness of breath in 78yr woman known to have COPD

4yr old girl has just woken up struggling to breathe and barking cough

Cough and chest pain with haemoptysis


Obstetrics and Gynaecology

28 week pregnancy with slight pv bleed

36 week pregnant with headache & oedema

15 year old with heavy and painful blood loss

28 week pregnant with chest pain

IUD fitted today, now has abdominal pains

32yrs iliac fossa pain, period late

17yr brown PV discharge and pelvic pain

21yr foul smelling PV discharge, feeling faint & fever

Neurological

39yr woman sudden onset of severe occipital headache

Unexpectedly confused 80yr lady, more than a week after a fall

A pyrexial twitching child

Pyrexial child with mottled rash

59 year old woman 1 hr history of weak right arm

Urological


39yr man with agonising loin pain

28 yr cyclist with pain in left testicle for past hour

Elderly man has not passed urine for 12 hours

Child with vomiting and rigors

18 yr man swollen penis for 6 hours

Psychological

Agitated, excited young man talking nonsense

Withdrawn morose nurse with access to insulin

34yr old man who split up with girlfriend, has been drinking & now threatening suicide

42yr schizophrenic man increasingly agitated & aggressive

Miscellaneous

Expected death of a 90 yr old woman in a nursing home

Unexpected death of 67 yr old man at home, history of angina


Appendix 4Out-of-hours Training for GP Specialty Registrars:Quality Assurance Monitoring Form

OOH Provider:Date of planned review:

In accordance with national agreement, Deaneries have a responsibility to quality manage the training received by GP Registrars in out-of-hours care. This quality monitoring form has been designed for use with out-of-hours care providers. The headings are those of the published PMETB domains. The form can be used as the basis of an annual review meeting between a Deanery representative, usually a local GP Associate Dean or GP

Training Programme Director, and the out-of-hours care provider. Feedback relating to training in out-of-hours care from GP Registrars will also be used in this quality management process. Out-of-hours care providers are asked to comment on each of the quality criteria and present supporting evidence at review.

Standard Comment Evidence to be presented

1. Patient Safety1.1 Written protocols on record keeping.1.2 A system of critical incident, reporting, analysis and feedback.1.3 An appropriate method of responding to patient comments and complaints and evidence that patients are involved in the organisation and development of the service (desirable).1.4 No trainee is expected to undertake an Out-of-hours session without appropriate supervision.

2. Quality Assurance, Review and Evaluation2.1 A system of audit of workload and practice that enables quality of care to be monitored and practice reviewed, as part of clinical governance.2.2 A system of information that enables the members of the OOH team to keep up to date with clinical and administrative matters relevant to OOH


work.2.3 A process for regular communication and review with the Deanery

3. Equality, Diversity and Opportunity3.1 A robust E&D policy for all employed staff3.2 Equity of access to available training sessions for all GP trainees

4. Recruitment, Selection and Appointment4.1 A robust E&D policy for all employed clinicians

5. Delivery of Curriculum including assessment5.1 A reliable method of transferring records of education to the trainee’s GP trainer. Normally this will entail completion of the “Record of Out-of-hours” session.5.2 Opportunities for trainees to learn from and about management and administration systems.5.3 Opportunities for trainees to appreciate how computerisation can contribute to clinical and organisational work in OOH (desirable).5.4 Where non-GPs are involved as educational supervisors, they will only supervise red sessions i.e. where the trainee takes no clinical responsibility.

6. Support and development of trainees, trainers and the local faculty6.1 A system of induction for all new staff.6.2 Evidence of good team working.6.3 An appropriate clinical supervisor for the whole of the trainee’s shift.6.4 Sufficient time within the session for teaching, feedback and completion of paperwork.


7. Management of Education and Training7.1 Effective and efficient management and administration systems.7.2 Methods of monitoring prescribing as an important part of the audit process and a formulary or prescribing policy including a statement on how the formulary is reviewed and implemented.7.3 Sufficient consulting rooms so that the GP trainee and clinical supervisor can consult during the same session.7.4 All clinical supervisors must be qualified to teach although they will not necessarily require the educational expertise required of GP trainers. (Suitability is defined in governance referred to above).7.5 There is an administrative system that ensures that all GP trainees are allotted appropriate sessions with clinical responsibility commensurate with their experience and competence.

8. Educational resources and capacity8.1 A workload that will enable trainees to acquire adequate clinical experience across the full range of age and disease.8.2 An appropriate range of diagnostic and therapeutic equipment for static and mobile use.8.3 An appropriate range and quantity of drugs for emergency and OOH use.8.4 Adequate secretarial and support staff to run the OOH system and encompass training.8.5 Sufficient transport so that the GP trainee and clinical supervisor can travel together as required on home visits.8.6 An environment that encourages multi-professional learning.


9. Outcomes9.1 Registers and indices that can be used for teaching, research and audit (desirable).9.2 There is a system of review, the purpose if which is to help clinical supervisors to reflect upon and develop their educational skills (desirable).

A meeting is held annually with deanery representative to review the above quality standards.Summary of feedback from GP registrars

Highlights


Recommendations

Signed on behalf of the Out-of-hours Provider Signed on behalf of the DeaneryDate

The deanery representative should ensure that the Out-of-hours care provider receives a copy of this form which should then be returned to:


Appendix 5


Appendix 6

Postgraduate Education for General Practice

GP Registrar Out of Hours Training Workbook



GP RegistrarOOH Registration Form

Clinical Information

To operate effectively, all Out of Hours organisations must have complete and accurate information on any clinician associated with it. This form is designed to record the information required for clinicians who are working for the organisation.Please help us by completing it promptly, legibly and in full!

Surname: First Name:Med Def cover Ref: Home Address:Expiring:GMC Reg No:Home Phone No.Practice Phone No.Mobile Phone No.Email addressLHBTraining Practice:GP Trainer:Dates of GP ST2 and ST3

OOH Provider Contact Details

OOH Provider:Contact Name: Other Contact Name:Address: Other Address:

Contact Tel No: Other Contact Tel No:Mobile No: Other Mobile No:Email: Other Email:

Please ask your trainer to complete the following:



OOH Training for GPSTRs

Trainer statement on Learning Needs of GPR

The following is a list of learning needs we have identified for this GPR, specific to unscheduled care:

Need Date identified Trainer’s name

Areas identified as needs in the OOH setting that may be addressed in hours:

Need Date identified Trainer’s name


Supervisor statement on Learning Needs of GPRidentified during OOH experienceThe following is a list of learning needs we have identified for this GPR, as a result of experience in OOH:

Specific SKILLS that need further development/experience are:

3



OOH Training for GPSTRsSelf statement on Learning Needs of GPRidentified during OOH experienceThe following is a list of learning needs I have identified for myself, as a result of experience in OOH:

Specific SKILLS that need further development/experience are:


OOH Training for GPSTRs

Wales Guidance


◗ You must NOT do any OOH work during your first month of experience in General

Practice – you should receive an induction prior to commencing OOH

◗ You will be required to fill out a ‘ Record of OOH session' page for each session, your OOH supervisor will also comment on this form at the end of each shift.

◗ The sheets are contained within this workbook and should be retained for inspection by your trainer.

◗ All shifts should ALSO be recorded within the LEARNING LOG section of the ePortfolio, under OOH sessions.

◗ These OOH sessions should be shared with your trainer, who will be able to see your progress towards your minimum of 72 hours throughout the year.

◗ Each entry for OOH should normally be linked to section 7 of the curriculum, Care of acutely ill people, and of course anywhere else that is appropriate

◗ This section of the curriculum also acts as the new focus for the learning outcomes you should attempt to achieve during your OOH experience. Below you will find the salient parts of this aspect of the curriculum, with the full link here:

http://www.rcgp-curriculum.org.uk/PDF/curr_7_Acutely_ill_people.pdf



Learning OutcomesPrimary care management◗Recognise and evaluate acutely ill patients.◗Describe how the presentation may be changed by age and other factors such as gender, ethnicity, pregnancy and previous health. ◗Recognise death.◗Demonstrate an ability to make complex ethical decisions demonstrating sensitivity to a patient’s wishes in the planning of care.◗Provide clear leadership, demonstrating an understanding of the team approach to care of the acutely ill and the roles of the practice staff in managing patients and relatives.◗Coordinate care with other professionals in primary care and with other specialists.◗Take responsibility for a decision to admit an acutely ill person and not be unduly influenced by others, such as secondary care doctors who have not assessed the patient.

The GP must be competent to provide out of hours care by demonstrating:◗ Ability to manage common medical, surgical and psychiatric emergencies in the out-of-hours setting◗ Understanding of the organisational aspects of NHS out-of-hours care◗ Ability to make appropriate referrals to hospitals and other professionals in the out-of-hours setting◗ Appropriate communication skills required for out-of-hours care◗ Individual personal time and stress management◗ Maintenance of personal security and awareness and management of the security risks to others.

Person-centred care◗Describe ways in which the acute illness itself and the anxiety caused by it can impair communication between doctor and patient, and make the patient’s safety a priority.◗ Demonstrate a person-centred approach, respecting patients’ autonomy whilst recognising that acutely ill patients often have a diminished capacity for autonomy.◗ Describe the challenges of maintaining continuity of care in acute illness and taking steps to minimise this by making suitable handover and follow-up arrangements.◗ Describe the needs of carers involved at the time of the acutely ill person’s presentation.◗ Demonstrate an awareness of any conflict regarding management that may exist between patients and their relatives, and act in the best interests of the patient.



Specific problem-solving skills◗ Describe differential diagnoses for each presenting symptom.◗ Decide whether urgent action is necessary, thus protecting patients with non-urgent and self-limiting problems from the potentially detrimental consequences of being over-investigated, over-treated or deprived of their liberty.◗ Demonstrate an ability to deal sensitively and in line with professional codes of practice with people who may have a serious diagnosis and refuse admission.◗ Demonstrate an ability to use telephone triage:

• to decide to use ambulance where speed of referral to secondary care or paramedic intervention is paramount• to make appropriate arrangements to see the patient• to give advice where appropriate.

◗ Demonstrate the use of time as a tool and to use iterative review and safety-netting as appropriate.

A comprehensive approach◗ Recognise that an acute illness may be an acute exacerbation of a chronic disease.◗ Describe the increased risk of acute events in patients with chronic and co-morbid disease.◗ Identify co-morbid diseases.◗ Describe the modifying effect of chronic or co-morbid disease and its treatment on the presentation of acute illness.◗ Recognise patients who are likely to need acute care and offer them advice on prevention, effective self-management and when and who to call for help.

Community orientation◗ Demonstrate an ability to use knowledge of patient and family, and the availability of specialist community resources, to decide whether a patient should be referred for acute care or less acute assessment or rehabilitation, thus using resources appropriately.◗ Deal with situational crises and manipulative patients, avoiding the inappropriate use of healthcare resources.

A holistic approach◗ Demonstrate an awareness of the important technical and pastoral support that a GP needs to provide to patients and carers at times of crisis or bereavement including certification of illness or death.◗ Demonstrate an awareness of cultural and other factors that might affect patient management.



Contextual aspects◗ Demonstrate an awareness of legal frameworks affecting acute healthcare provision especially regarding compulsory admission and treatment.◗ Demonstrate an awareness of the tensions between acute and routine care and impact of workload on the care given to the individual patients.◗ Demonstrate an awareness of the impact of the doctor’s working environment and resources on the care provided.◗ Demonstrate an understanding of the local arrangements for the provision of out-of-hours care.

Attitudinal aspects◗ Demonstrate an awareness of their personal values and attitudes to ensure that they do not influence their professional decisions or the equality of patients’ access to acute care.◗ Identify patients for whom resuscitation or intensive care might be inappropriate and take advice from carers and colleagues.◗ Demonstrate a balanced view of benefits and harms of medical treatment.◗ Demonstrate an awareness of the emotional and stressful aspects of providing acute care and an awareness that they need to have strategies for dealing with personal stress to ensure that it does not impair the provision of care to patients.

Scientific aspects◗ Describe how to use decision support to make their interventions evidence-based, e.g. Cochrane, PRODIGY, etc.◗ Demonstrate an understanding of written protocols that are available from national bodies and how these may be adapted to unusual circumstances.◗ Evaluate their performance in regard to the care of the acutely ill person; including an ability to conduct significant event analyses and take appropriate action.

Psychomotor skills◗ Performing and interpreting an electrocardiogram.◗ Cardiopulmonary resuscitation of children and adults including use of a defibrillator.◗ Controlling a haemorrhage and suturing a wound.◗ Passing a urinary catheter.◗ Using a nebuliser.


The knowledge baseSymptoms◗ Cardiovascular – chest pain, haemorrhage, shock.◗ Respiratory – wheeze, breathlessness, stridor, choking.◗ Central nervous system – convulsions, reduced conscious level, confusion.◗ Mental health – threatened self-harm, delusional states, violent patients.◗ Severe pain.

Common and/or important conditions◗ Shock (including no cardiac output), acute coronary syndromes, haemorrhage (revealed or concealed), ischaemia, pulmonary embolus, asthma.◗ Dangerous diagnoses (see Appendix 3).◗ Common problems that may be expected with certain practice activities: anaphylaxis after immunisation, local anaesthetic toxicity and vaso-vagal attacks with, for example, minor surgery or intra-uterine contraceptive device insertion.◗ Parasuicide and suicide attempts.

Investigation◗ Blood glucose.◗ Other investigations are rare in primary care because acutely ill patients needing investigation are usually referred to secondary care.

Treatment◗ Pre-hospital management of convulsions and acute dyspnoea.

Emergency care◗ The ‘ABC’ principles in initial management.◗ Appreciate the response time required in order to optimise the outcome.◗ Understand the organisational aspects of NHS out-of-hours care.◗ Understand the importance of maintaining personal security and awareness and management of the security risks to others.Resources◗ Appropriate use of emergency services, including logistics of how to obtain an ambulance/paramedic crew.◗ Familiarity with available equipment in own car/bag and that carried by emergency services.◗ Selection and maintenance of appropriate equipment and un-expired drugs that should be carried by GPs.◗ Being able to organise and lead a response when required, which may include participation by staff, members of the public or qualified responders.◗ Knowledge of training required for practice staff and others as a team in the appropriate responses to an acutely ill person.Prevention◗ Advice to patients on prevention, e.g. with a patient with known heart disease, advice on how

to manage ischaemic pain including use of glyceryl trinitrate (GTN), aspirin and appropriate first-line use of paramedic ambulance.



Record of OOH session Type of session (e.g. base doctor (including walk-in centre), visiting doctor, telephone triage, minor injuries centre):

Date of session:

Time of session and length (hours):

Type of cases seen and significant events

Learning areas and needs identified (to be discussed with GP Trainer)

Debriefing notes from Clinical Supervisor

Name of OOH Supervisor:

Signature of OOH Supervisor:

Signature of GP Registrar:


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